Failure to Timely Report and Investigate Alleged Misappropriation of Resident Jewelry
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of a resident’s property to the state agency, as required by policy and regulation. The affected resident was admitted with multiple significant diagnoses, including COPD, lung cancer, hemiplegia and hemiparesis after stroke, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage 2 chronic kidney disease, and was receiving hospice services. A quarterly MDS showed the resident had a BIMS score of 14/15, indicating intact cognition. The resident was moved from one room to another on Unit 2, and following this room change, the resident reported that several personal items, including two gold rings (one with a purple stone and one with a green stone), were missing. An anonymous complaint later alleged that after the room change, several items were missing, including an antique amethyst birthstone ring described as real gold with a [NAME]-cut stone that was beveled from years of wear, and another gold ring with a green stone. The complaint stated the missing items had been reported to social services but had not been located or replaced, and that the resident reported the Administrator refused to replace the ring or reach an amicable solution. The volunteer Ombudsman visited the facility and spoke with a Unit Manager about the missing rings; the Unit Manager stated she would relay the concern to management. When interviewed, the Administrator initially reported there were no grievances or concerns filed in the last three months and that he was not aware of any concerns regarding missing jewelry. Subsequent interviews and record review showed that the resident had, in fact, reported the missing rings to the Administrator on the day of the room change, and the rings remained missing at the time of survey. The Administrator later confirmed he was aware of the allegation a few days after the room change but did not complete a concern/grievance form and did not submit a self-reported incident to the state agency because he felt the resident could not adequately describe the rings or when she last saw them and was not convinced the resident had the rings. The Social Worker reported searching the resident’s room and speaking with staff but had no documented evidence of an investigation. Neither the Administrator nor the Social Worker contacted the resident’s family to confirm the presence of the rings at the facility. These actions and omissions were inconsistent with the facility’s written policy, which required immediate reporting of misappropriation allegations (no later than two hours after the allegation), timely investigation with documented statements and findings, and submission of investigation results to the state agency within five working days.
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